Dialysis Clinic Inc. of Southpoint

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 35966 Based on observation and interview, the facility failed to ensure two Patient Care Technicians (PCT), followed acceptable infection control practices during patient care. (Staff A & Staff D) The findings include: 1. During a random observation of Staff D at 9:30 am on 9/15/25, the PCT was wearing gloves while assisting a patient to the restroom. After the patient entered the restroom and the door was closed, the PCT was observed removing his gloves and gown the left the treatment floor without performing hand hygiene. 2. During a random observation of Staff A at 9:36 am on 9/15/25, the PCT was observed removing the bloodlines and disposable equipment from Station #1. He disposed of the items into a biohazard waste bin, removed his gloves, then donned new gloves without performing hand hygiene. 3. During an observation of Discontinuation of Dialysis and Post Dialysis Access Care for Fistula/Graft on 9/15/25 at 9:39 am, Patient #11 was observed holding his access with a gloved hand. When the patient reached hemostasis and exited the treatment area, Staff A did not remind the patient to perform hand hygiene. 4. During an observation of Discontinuation of Dialysis and Post Dialysis Access Care for Fistula/Graft on 9/15/25 at 9:45 am, Patient #12 was observed holding her access with a gloved hand. When the patient reached hemostasis and exited the treatment area, Staff A did not remind the patient to perform hand hygiene. 5. During a random observation of Staff D at 10:25am on 9/15/25, the PCT was observed using the same gloves to touch the dialysis machine at Station #8 that he had previous used at Station #6. 6. During a random observation of Staff A at 10:37 am on 9/15/25, the PCT was observed touching the dialysis machine at Station #4 with a glove wrapped around his finger. 7. During an observation of of Staff D on 9/15/25 at 10:40 am, the PCT performed Initiation of Dialysis of a Fistula at Station #6, removed his gloves, and donned new gloves to clean the dialysis machine at Station #11. No hand hygiene was performed between glove changes. 8. During a random observation of Staff D on 9/17/25 at 7:05 am, the PCT was observed working at Station #16 wearing gloves. He went to the staff area near Station #16 and began writing on a sheet of paper. He sat in a chair in the staff area until 7:17 am. The PCT walked to Station #19 and began to touch the dialysis machine with the same gloves. He then removed his gloves and donned new ones without performing hand hygiene. 9. During a random observation of Staff D on 9/17/25 at 7:40 am, the PCT was touching the dialysis machine at Station #17. He then moved to touch the dialysis machine at Station #16 when he was stopped by the surveyor and told to remove his gloves and perform hand hygiene. The PCT stated “this hand is clean and this one is dirty so I won’t touch the machine with the dirty hand”. The facility policy titled “Infection Control in Dialysis” states “Hand hygiene will be performed: after touching blood, body fluids, secretions, excretions, and potentially contaminated items; before and after direct patient contact; before invasive procedures such as vascular access cannulation or administration of parenteral medications; immediately after gloves are removed; after contact with inanimate objects; before entering and upon exiting the patient treatment area; when moving from a contaminated body site to a clean body site of the same patient; before and after palpating catheter insertion sites; and before and after accessing or dressing an intravascular catheter”. During an interview with Patient #14 on 9/15/25 at 12:00 pm, it was stated that she only sees staff changing gloves. She stated she does not see them using the hand sanitizer or washing their hands. During the interview with the Charge Nurse on 9/17/25 at 7:45 am, it was stated that the staff members were new to dialysis but had been trained on proper infection control practices. She confirmed that infection control is something that is talked about “all the time”.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 35966 Based on observation, review of the facility policy and staff interview, the facility failed to ensure the staff member disinfected the patient thermometer prior to the next patient and between patients. (Staff #D). The findings include: During a random observation of Staff #D (PCT) on 9/15/25 at 11:55am, a temporal artery thermometer was observed sitting on top of the dialysis machine at Station #10. Staff D was working at Station #9. Without removing his gloves, the PCT picked up the thermometer from Station #10 and used it on the patient at Station #9. He then placed the thermometer on the clean supply cart without disinfection or removing his gloves. He then continued to care for the patient at Station #9. The facility policy titled “Routine Disinfection in the Hemodialysis Unit” states “Thermometers will be disinfected after each use. Thermometers will not be taken to the patient station and placed back in common area until it has properly been disinfected.” The interview with the Charge Nurse on 9/15/25 at 1:30 pm confirmed that the thermometer should have been disinfected.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 35966 Based on observation, review of policies and procedures, and staff interview, the facility failed to follow infection control precautions for Cleaning and Disinfection of the Dialysis Station for 2 of 2 observations. The findings include: 1. Cleaning and Disinfection of the Dialysis Station was observed on 9/15/2025 at 10:30am at Station 3. The hemodialysis machine was cleaned down from top to bottom. Staff A, a Patient Care Technician (PCT) did not empty the prime waste container and sanitize it before another patient occupied the dialysis chair. 2. Cleaning and Disinfection of the Dialysis Station was observed on 9/15/2025 at 10:40am at Station 11. The hemodialysis machine was cleaned down from top to bottom. Staff D, a Patient Care Technician (PCT) did not empty the prime waste container and sanitize it before another patient occupied the dialysis chair. Interview with the Charge Nurse on 9/15/25 at 1:30pm confirmed the prime waste bucket was to be cleaned inside and out regardless of use after each treatment. Review of the policy and procedure titled “Infection Control in Dialysis” states “At the end of each patient treatment, staff should clean and disinfect the dialysis station, discard all fluids, and clean and disinfect all surfaces of the containers associated with the prime waste”.”

“PERSONNEL-TRAINING PROGRAM/PERIODIC AUDITS CFR(s): 494.40(a) 9 Personnel: training program/periodic audits A training program that includes quality testing, the risks and hazards of improperly prepared concentrate, and bacterial issues is mandatory. Operators should be trained in the use of the equipment by the manufacturer or should be trained using materials provided by the manufacturer. The training should be specific to the functions performed (i.e., mixing, disinfection, maintenance, and repairs). Periodic audits of the operators’ compliance with procedures should be performed. The user should establish an ongoing training program designed to maintain the operator’s knowledge and skills. This Standard is not met as evidenced by: 35966 Based on interview and personnel file record review, the facility failed to have periodic audits (not less than annually) of staff conducting water and dialysate mixing, dialysate testing, dialysate pH and conductivity testing at the point of use (Hemodialysis machines) for 1 of 3 staff members reviewed. (Staff C) The findings include: Personnel file record review showed the last water systems audit of Staff C (Nurse) was performed on 10/12/2023. The interview with the Nurse Manager on 9/17/2025 at 9:50 am confirmed the water system audits are to be performed annually.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 35966 Based on record review and staff interview the facility failed to implement the physician ordered dialysate flow rates (DFR) for 2 of 5 patients reviewed. (Patient #2 & Patient #3) The findings include: 1. Record review of the treatment record for Patient #2 showed that the patient had physician orders for a DFR of 800 ml/min. On 8/27/2025, the patient was on hemodialysis for 3.5 hours with a set DFR of 600 ml/min. Staff documented that the patient was alert and resting comfortably. Interview with the Charge Nurse on 9/16/2025 at 10:30 am confirmed the DFR was set incorrectly with no documentation indicating why the physician orders were not followed. 2. Record review of the treatment record for Patient #3 showed that the patient had physician orders for a DFR of 800 ml/min. On 8/27/2025, the patient was on hemodialysis for 4.13 hours with a set DFR of 600 ml/min. Staff documented that the patient was alert and resting comfortably. Interview with the Charge Nurse on 9/16/2025 at 10:35 am confirmed the DFR was set incorrectly with no documentation indicating why the physician orders were not followed.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 35966 Based on patient treatment record review and staff interview, the facility failed to maintain complete and accurate medical records for 1 patient (Patient #2) out of 5 patients sampled. The findings include: The review of Patient #2 treatment record showed on 9/10/2025, the patient was ordered to receive Heparin 7000 units loading dose during dialysis. The record showed no documentation to verify the patient received the 7000 units of Heparin as ordered by the physician. During the interview the the Charge Nurse on 9/16/2025 at 11:15 am, it was confirmed the medication documentation was missing.”